Creog-OB
risk of uterine rupture with prior low transverse incision
0.5-0.9%
risk of transmission of HIV if viral load < 1000 for HIV
1-2%
3 main reasons for pLTCS
1. FTP 2. NRFHT 3. malpresentation
3 highest risk factors for abruption
1. h/o abruption 2. AMA 3. cHTN
recurrence risk of shoulder dystocia
10%
Nuchal translucency
10-13w, Require CRL between 38 and 84mm. >or equal to 3.0mm, or >99%ile for CRL. 1/3 with increased translucency will have aneuploidy
chorionic vilous sampling gestational age. Risk of fetal loss?
10-14w, 1:455
amount of iron intake required in pregnancy
1000 mg total or 27 mg a day
two dose regimen for mtx
50mg/m2 IM day 1 and day 4. measure hcg day 4 and 7. if it does not increase >15% give third dose on day 7. recheck hcg day 11. Can give up to 4 doses. give to women with higher starting hcg (3600)
dose of methotrexate
50mg/m2 IM, hcg must fall by at least 15% after 7 days, measure bhcg on day 4 and 7. May administer another dose, then surgery
When to delivery for BPP score
6/10: deliver of >37w, if <37w repeat in 24 hr oligohydramnios= deliver if >36w 4/10: deliver is >32w <4/10: deliver
how far into a pregnancy can a medical abortion occur?
63 days
magnesium dose for neuroprotection magnesium dose for tocolysis
6g bolus with 2g/hr is <32 w 6g bolus
Dexamethasone steroid dose for PTL
6mg x4 IM, q12h
when to place an IUD PP
6w
abx treatment for PPROM
7 days total of IV ampicillin and erythromycin (first 2 days) followed by PO amoxicillin and erythromycin (or azythromycin) during expectant management only give if >20w
Test to determine if vaginal bleeding is fetal blood
Apt test
false positive nitrazine
BV, blood, semen, soap
Causes of echogenic bowel
CF, CMV, Down syndrome, aspiration of blood.
requirements for cephalic/breech vaginal deliver
EFW >1500g Baby A lager than B Twin discordance <20% No more than 2 prior c/s
delivery of diabetic mothers
GDMA1- by 41w GDMA2 well controlled- 39w GDMA2 uncontrolled- 37-38w pregestational diabetes- controlled 39w uncontrolled- 37-38w
Which Hgb is aftected by beta thalasemia?
Hgb A= alpha2beta2 Increased Hgb F= apha2delta2
treatment for breast abscess
I&D Vanc to cover MRSA or Bactrim
contraindications to tocolysis
IUFD, lethal fetal anomaly, NRFHT, severe PreE or E, maternal instability, chorio, PPROM, multiple gestations, (abruption?)
tx of ITP
IVIG, dexamethasone, or prednisone when platelets are < 30,000 >50,000 for c/s >80,000 for epidural
Rh antibodies and antigens
IgG, crosses the placenta antigens= C, c, D, E, e
epidural location
L4-L5
rates of delivery of PTL
30% resolve spontaneously <10% deliver in 7 days 50% deliver at term
Dose of rhogam
300 mcg coveres 30 cc of fetal rbcs 50-120 mcg if <12w
when to deliver mono-mono twins
32-34w, always by c/s to prevent cord entanglement
when to deliver placenta accreta
34-36w
when to deliver mono-di twins
34-38w
when to deliver vasaprevia
35-36w
when to deliver if h/o prior uterine rupture
36-37 w
when to deliver if h/o classical c/s or h/o uterine rupture
36w
when to switch from heparin to LMWH
36w
when to deliver chtn with no complications
38-39w
when to deliver di-di twin
38w
when to do C/s for HIV
38w if viral load >1000
how long does it take for a uterus to completely involute
4 weeks
when to restart anticoagulation
4-6 hr after vaginal delivery 6-12 hor after c/s 4 hr after removal of epidural 24 hr after spinal
magnesium dose for preE
4g, 2g/hr 6g if eclampsia if eclampsia and already on mag, give a 2g bolus.
when does the neural plate form?
5 weeks
maternal caloric requirement for breastfeeding
500 calories daily
average blood flow to uterus at term
500 cc/min
Listeria treatment and symptoms
abscesses in fetus and placenta- culture placenta exposure= test if symptomatic symptoms but no fever= BCx and exp managment Febrile= BCx and ampililin IV 2g q4h, 7 days
treatment for varicella
active lesions in pregnancy- oral acyclovir within 24 hr maternal pneumonia= IV acyclovir infants who develops varicella by 2w of life= IV acyclovir mother develops varicella 5days prior-2 days PP= treat infant with VZIg Pregnancy exposure= VZIg and acyclovir within 72 hours
most common site of ectopic implantation
ampulla
when to use vaginal progesteron
asymptomatic with no history of preterm birth and cervical length <20mm at <24w
when to do a classical c section for transverse lie
back down
Neonatal encephalopathy
base excess >12, pH<7, 2 MRI showing injury, metabolic acidosis
delayed cord clamping in preterm infants
better blood volume, lower incidence of necrotizing enterocolitis, lower incidence of intraventricular hemorrhage
absolute contracindications to methotrexate
breastfeeding, immunodeficiency disorder, alcoholism, chronic liver disease, anemia, leukopenia, thrombocytopenia, sensitivity to methotrexate, active pulmonary disease, peptic ulcer disease, renal disease, intrauterine pregnancy, reptured ectopic, hemodynamic instability
erb palsy klumpkies palsy
c5-c6 c7-t1
tx for transfusion associated citrate toxicity
calcium chloride causes hyperkalemia, hypocalcemia, and acidosis
risk of indomethacine
can constrict ductus ateriosus and cause necrotizine enterocolitis
US indicated cerclage
cervical length <25mm between 16-24w and history of preterm delivery at <34w
Prerequisites for operative vaginal delivery
cervix fully dilates membranes ruptured engagement of the fetal head determine position of fetal head estimate fetal weight pelvis thought to be adequate for vaginal birth adequate anesthesia maternal bladder empty patient agree to risks and benefits willingness to abandon operative delivery with backup in place
what has the highest risk of fetal-maternal hemorrhage
chorionic villus sampling
changed in cervix in labor
collagen breakdown, glycosaminoglycans, increased cytokins, wbc infiltration
ultrasound findings diagnostic of pregnancy failure
crown-rump length > or equal to 7mm and no heartbeat mean sac diameter of > or equal to 25mm and no embryo abscence fo embryo with heartbeat 11 days or more after a scan that showed a gestations sec with a yolk sac absence of embryo with heartbeat 2 weeks or more after a scan that showed a gestational sac without a yolk sac
day of separation causing what twin type
day 1-3= di di day 3-8= mono-di day 8-13= mono-mono day 13-15= conjoined >15 days= singleton fetus
systemic vascular resistance in pregnancy
decreases due to progesterone. Decrease peaks at 24 weeks and slowly returns to pre-pregnancy BP. should never exceed it
indication for cerclage
history of cervical insufficiency history of cerclage for painless cervical dilation in the 2nd T painless cervical dialation in the 2nd T cervical length <25mm <24w with history fo preterm birth <34w
side effect of oxytocin bolus
hypotension
MCA velocity
if MCA is > 1.5 MoM, transfuse through PUBs
causes of hydrops
immune= Rh or Kell Non-immune= infectious, cardiac (SVTs), aneuploidy, TTTS, sacrocoxygeal teratoma Must have 2 (skin, amniotic fluid, ascites, cardiac, pulm)
hcg levels that indicated ectopic
increase in hcg, plateau, or decrease<15%
treatment for latent TB w/ average progression risk Latent TB w/ elevated progression risk Active TB
isoniazide w/ B6 for 9 mo started 2-3 mo after delivery insoniazide w/ B6 for 9 mo after first trimester Isoniazide w/ B6 and rifampin for 9mo +/- ethambutol
most common sex chrosomsome aneuploidy
klinefelter syndrome
breech maneuvers
loveset= flex elbow to sweep arm down past the face mauriceau= press on maxillae to flex head pinard= fetal thigh, flex knee, move laterally, deliver foot prague= used if fetal back is posterior to deliver legs while keeping head flexed
kronig incision
low veritcle incision
General anesthsia in labor
main risk is hypotension minimal effects on newborn can begin breast feeding right away
what causes complete heart block
maternal SSA and SSB IG crossing placenta in lupus More likely to be Anti-Ro than Anti-La
Criteria for chorio
maternal fever AND: maternal leukocytosis purulent cervical drainage fetal tachcardia
side effects of epidural
maternal tachycardia, hypotension, increased maternal temperature
treatment of ovaries in turner syndrome
may contain gonadoblastomas. remove prior to puberty. Give HRT with estrogen. Give progesterone for breakthrough bleeding. Add progesterone at puberty, will cause breast growth
which type of episiotomy is recommended?
mediolateral
which face presentation can be delivered vaginally?
mentum anterior
dose of blood loss drugs
methergine IM 0.2mg q2-4hr, can cause N/V hemabate IM 0.25 mg q 15min, 8 ose max
methergine
methylergonovine, 0.2mg IV
how to induced prior to 28 weeks
misoprostol is best option. After, manage like any other laborer, cook balloon in a good option
autonomic dysreflexia
most serious medical compication in women with spinal cord injuries above T6. Treat with neuraxial anesthsia. Severe hypertension, cardiac arrhythmias, HA, sweating, massive sympathetic response
contraindication to magnesium
myasthensia gravis
amoxicillin-clavulanic acid (augmentin) is associated with what in pregnancy?
necrotizing encterocolities
contractions stress test results
negative= no decels positive= decels with >50% of ctx equivocal-suspicious- intermitent decels equivocal= decels with ctx >2 min apart or >90s, hyperstimulatory unsatisfactory= <3 ctx in 10 min
histologic change in dilating cervix
neutrophils release protease hyaluronan draws in water collagen reduced 30-50%
treatments for GBS
no allergy= pen G 5 mil U loading, 3 mil U q4h low risk allergy= ancef 2g loading, 1g IV q8h Anaphylaxis clinda susceptible= clinda 900 mg IV q8h Anaphylaxis resistant or unknown= van 20 mg/kg q8h
risk of accreta with a previa
no prior c/s= 3% 1 prior= 11% 40% 61% 67%
risk factors for postterm pregnancy
nulliparity prior post term pregnancy male fetus maternal obesity anencephaly placental sulfatase deficiency
risk factors for post-term pregnancy
nulliparity, prior post term pregnancy, male fetus, materanl obesity, anencephaly, placental sulfatase deficiency
gastroschisis vs omphalocele
omphalocele is midline. Associated with other genetic abnormalities Gastroschisis- right of midline. sporadic. C/s not necessary. Related to IUGR
Diagnosis of antiphospholipid syndrome
one clinic criteria and one laboratory criteria clinical: vascular thrombosis 1 or more fetal death after 10w 1 or more births <34w due to preE, E, IUGR 3 or more unexplained fetal loses <10w laboratory: lupus anticoagulant x2 12 w apart anticardiolipin ab of IgG or IgM x2 12 w apart Anti-B2 glycoprotein 1 of IgG or IgM x2 12 w apart
when to give rescue steroids
only if <34w and >7 days prior
when to tocolyse PTL
only through steroid window <34w
what is 1:1:1?
pRBC, FFP, and cryo
which SSRI causes congenital malformations?
paroxetine, cardiac malformations
Other meds in eclampsia
pheytoin, amobarbital, thiopental
membrane stripping releases what?
phospholipase A2 and PGF2a
suture used for cerclage
polydioxanone (PDS) uncoated polymer
how long to wait for LEA after lovenox and heparin
prophylactic lovenox= 12 hr theraputic lovenox= 24 hr prophylactic heparin= 4-6hr theraputic heparin= 12 hr
hemabate
prostin, PGF2, 15-methylprostaglandin F2alpha IV 0.25mg q15min x 8 doses
diagnosis of T2DM in normal female
random glucose > or equal to 20 fasting glucose > or equal to 126 2hr gtt > or equal to 200 A1c > or equal to 6.5%
High spinal
regional anesthesia travels higher than expected into the chest. Causes hypotension, nausea, vomiting, loss of consciousness, aspiration, airway compromise. Tx= L lateral uterine displacment, pressors, respiratory support. Caused by intrathecal injection instead of epidural, trendelenburg
is gadolinium MRI safe?
safe in breast feeding not safe in pregnancy, risk of rheumatologic disease in fetus
chorio most sensitive and specific test
sensitive= IL-6 specific= culture
TOLAC with twins
similar outcomes to singletons
maylard incision
similar to pfannensteil but the rectus ot dissected away from the rectus abdminis muscles and the bellies of the muscles are transected. require ligation of the inferior epigastric vessels
kuster incision
slighyl curved, below ASIS, just below pub hair line
treatment for mastitis
staph aureua dicloxacillin 500 mg x10-14 days
when do neural tube defects occur
start at 5 weeks, close by 6 weeks
joel-cohen incision
straight transverse incision, 3cm below ASIS
what acute treatments are best for systolic vs diasolic bp
systolic- labetalol diastolic- hydralazine and nifedipine
Best way to prevent nausea in pregnancy
take PV one month prior to conveing
cherney incision
tends of the rectus abd and pyramidalis are transected 1-2 cm above their insertion at the pubic symphysis, lifted cephalad
preexposure prophylaxis for HIV
tenofovir and emtricitabine
treatment for septic pelvic thrombophlebitis
theraputic heparin or LMWH for 7-10 days
only features of preE that require delivery even if not steroids
uncontrolled severe HTN, eclampsia, pulmonary edema, abruption, DIC, NRFHT, intrapartum fetal demise
relative contraindications to methotrexate
unruptured mass <4cm, no fetal cardiac motion, hcg <5,000, refusal to except blood transfusions, hcg rising by >50% in 48hr
how long can a delayed PP hemorage occur
up to 12 w PP
risk of rupture after previous uterine rupture
upper segment= 32% lower segment= 6%
spinal headache
worse when standing. Casued by leakage of CSF
calculate vials of rhogam
(% fetal cells x 5000 cc)/ 30cc + 1 vial
alpha thalasemia major
(a-/--) hemoglobin H, moderate anemia (--/--) Hb Barts, hydrops fetalis, IUFD, PreE
when to deliver placenta previa
36-37 weeks
what to order next if HBsAg is positive
HBV core antigen IgG and Ig, LFTs, viral load
critical titers for anti-D When to give rhogam
between 1:8 and 1:32, if <1:8, follow every 4 weeks for testing If paitent has Ati-D and is bleeding, gets titers, dont give rhogam
contraindications to operative delivery
bone demineralization, bleeding disorders
contraindications to cell saver
bovie electrocautery= carbon monoxide Clotting agents= surgical fat contamination irrigating solutions= betadine
when to give rhogan
delivery, SAB, ectopic, cordocentesis, amniocentesis, CVS, ECV, trauma, hemorrhage. Give of > 0.1cc blood loss
abx for suction D&C
doxycyline 200 mg 1 hour prior to D&C
exam indicated cerclage
emergent cervix 1-4cm dilated and <24w with NO history of preterm delivery
what is in cryoprecipitate
factor VIII, XIII, fibrinogen, and VWF
most common sign after uterine rupture
fetal bradycardia
compound presentation
fetal vertex along with fetal extermity presenting
fetal blood volume at term with and without placenta
fetus= 78 cc/kg fetus + placenta= 125 cc/kg
treatment for endomyometritis
gent and clinda amp treats enterococcus
post exposure prophylaxis for HIV
given < 72 hours, tenofovir/emtricitabine and raltegravir
what do you do if a 4th degree lac is later found in clinic?
go to the OR to repair
baseline preterm birth rate in US
12%
when are cerclages placed?
12-14weeks
when does fetus start to develop is own thyroid hormone
12w
risk of alloimmunization if mom does not get rhogam
13%
when to offer vaginal progesteron
16-24w h/o PPROM CL <20mm
twin risk of death and nerologic injury for mono-di and di-di if one twin dies
18% neurologic injury in mono-di 15% death in mono-di 3% death in di-di 1% neurologic injury in di-di
risk of down syndrome at age 35
1:190
Most predictive US measurment of gestational age?
1st T CRL 2nd T head circumference 3rd T femur length (cerebellum)
excess bleeding after MAB
2 pads per hour for 2 hours
radiation exposure that causes congenital anomalies
20 Rads
dose of mifepristone for early pregnancy loss
200 mg PO 24 hours before misoprostol
quad screen results for trisomy 21 and 18
21= decreased MSAFP and estriol. Increased beta-hcg and inhibin A 18= decreased all
when can you use FFN
22-34w Low PPV, high NPV dont use with vaginal bleeding or advance dilation Can be used in twins can use if recent intercourse
amount of iodine intake in pregnancy vs breastfeeding
220 ug 290 ug when breastfeeding
discriminatory bhcg level to visualize a pregnancy
3,500
Rhogam dosage
<12w 50-120 ug >12w 125-300 ug
what membrane thickness between amniotic sac indicated monochorionic twins
<2mm
what gestational age is rhogam not indicated
<7w
US discrepancy in dating
<9w use US if >5 day difference 9-16w, >7 days >16w, >10 days 16-28w, 14 days Third trimester, 3 weeks
what gestational age can you do amniocentesis? Risk of fetal loss?
>14w, 1:370-1:900
when to give an additional dose of ancef
>1500cc blood loss or > 4 hr
when to start combined OCPs postpartum
>3 weeks PP, increased risk of DVT. best if 6w
when do you expect to see accelerations 15x15
>32 weeks <32 weeks= 10x10
bishop score consistent with favorable cervix
>8 (9 or more)
Noonan syndrome
AD, PTPN11 gene, Short stature, characteristic facial features, pulmonic stenosis, lymphatic dysplasia, intellectual disability, pectus deformity, coagulation defects, renal abnormalities.
nifedipine dose for tocolysis terbutaline dose
PO 30mg loading, then 10-20mg q4-6hr 0.25mg q20min
stages of TTTS
Stage 1= poly MVP >8cm in one twin and oligo <2cm in the other stage 2= donor's bladder is not visible stage 3= umbilical artery doppler are abnormal stage 4= hydrops stage 5= fetal death
